Healthcare Provider Details

I. General information

NPI: 1730609959
Provider Name (Legal Business Name): SHANNON SIRACUSA LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHANNON SIRACUSA LMHC

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1777 TAMIAMI TRL STE 201
PORT CHARLOTTE FL
33948-1064
US

IV. Provider business mailing address

1777 TAMIAMI TRL STE 201
PORT CHARLOTTE FL
33948-1064
US

V. Phone/Fax

Practice location:
  • Phone: 841-249-4354
  • Fax:
Mailing address:
  • Phone: 841-249-4354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH22831
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: